Welfare Reform on the Web (November 2008): Healthcare - overseas

Changes in out-of-pocket payments for healthcare in Vietnam and its impact on equity in payments, 1992-2002

A. Chaudhuri and K. Roy

Health Policy, vol. 88, 2008, p. 38-48

Economic reforms initiated in Vietnam in the late 1980s included deregulation of the healthcare system resulting in extensive changes in delivery, access, financing and use. One aspect of health sector reform was the introduction of user fees at both public and private facilities, which was in stark contrast to the former socialist system of free medical care. Subsequently, health insurance and free healthcare cards for the poor were introduced to overcome the barriers to seeking care and reduce the financial burden of out-of-pocket payments. This paper examines the impact of the reform on individual healthcare utilisation, focusing on the relationship between households' ability to pay and individual household members' out-of-pocket payments for healthcare.

The emergence of proprietary medical facilities in China

X. Hou and J. Coyne

Health Policy, vol. 88, 2008, p. 141-151

This article describes the emergence of private, for-profit medical facilities in China since the 1980s. It identifies the market conditions which have favoured their development in the shape of excess demand which could not be satisfied by the public system, the emergence of a wealthy elite with money to pay for high quality care and the ready availability of investment capital. It also traces the development of favourable government policies. It further explains why non-profit healthcare facilities are not favoured by the current Chinese healthcare market.

Ex-ante evaluation of PFIs within the Italian health-care sector: what is the basis for this PPP?

A. Barretta and P. Ruggiero

Health Policy, vol. 88, 2008, p. 15-24

The partners in private finance initiatives (PFIs) in Italy usually have no pre-existing relationship with each other and no basis for mutual trust. An ex-ante evaluation process can facilitate the building of a relationship of trust between the public and private organisations involved in a PFI. However the evaluation process should be carried out from the private partner perspective, the public partner perspective and the perspective of the community. This study shows that Italian healthcare trusts, which are not required to use an approved methodology for pre-evaluating PFIs from their own perspective, neither calculated the future costs and benefits of the project nor considered the social consequences for the community. They merely followed the legal requirements to the letter and prepared a financial plan from the private partner perspective. As a consequence, the majority of healthcare trusts demonstrated no positive expectations regarding the future development of the partnership.

Financing the package of services during the first decade of the national health insurance law in Israel

A. Shmueli, L. Achdut and M. Sabag-Endeweld

Health Policy, vol. 87, 2008, p. 273-284

The Israeli National Health Insurance Law was introduced in 1995. The law established the right of every inhabitant to health insurance and services, and defined a comprehensive uniform package of health services to be provided by four competing sickness funds. The Law specified the sources of finance for the package, and the method by which the health services budget would be updated. This review indicates that between 1995 and 2005 the 'real value' of the budget financing the package of services has eroded by more than a third, most of this being due to under-updating to cover technological advances. The shortfall has been covered by a steep rise in co-payments by users and the spread of supplementary private health insurance.

Gender and health: the effects of constrained choices and social policies

C. Bird and P. Rieker

Cambridge: CUP, 2008

The book argues that to improve men's and women's health, individuals, researchers, and policymakers must understand the social and biological sources of the perplexing gender differences in illness and longevity. Although individuals are increasingly aware of what they should do to improve health, competing demands for time, money, and attention discourage or prevent healthy behaviour. Drawing on research and cross-national examples of family, work, community, and government policies, the book develops a model of constrained choice that addresses how decisions and actions at each of these levels shape men's and women's health-related opportunities. Understanding the cumulative impact of their choices can inform individuals at each of these levels how to better integrate health implications into their everyday decisions and actions.

Getting real performance out of pay-for-performance

S. Nicholson and others

Milbank Quarterly, vol. 86, 2008, p. 435-457

Most private and public health insurers in the USA are implementing pay-for-performance programmes in an effort to improve the quality of medical care. The authors argue that pay-for-performance based on process-of-care measures can affect outcomes (the ultimate goal) only insofar as the rewarded processes reliably lead to better outcomes, and that the processes now being rewarded are only weakly linked to better outcomes. This limits the value of pay-for-performance as a healthcare improvement strategy. Basing pay-for-performance programmes on outcomes would seem to avoid this limitation. It is argued that such an approach would work best when purchasers know less than providers about which processes produce health improvements and when purchasers are able to risk-adjust measures of patients' health status. Conversely, it is argued that outcomes-based pay-for-performance approaches would be unnecessary if definitive information were available about the health production function or if provider-specific, severity-adjusted outcome data were available and actually used by patients to select service providers. Under the former conditions, well-designed fee-for-service payments would work, and under the latter conditions, patient choice of providers would supersede pay-for-performance.

Health sector reforms in Argentina and the performance of the health financing system

E. Cavagnero

Health Policy, vol. 88, 2008, p. 88-99

Between 1993 and 2002 Argentina implemented a number of health sector reforms aimed at introducing managed care and market-oriented policies. There was particular emphasis on the decentralisation and self-management of the tax-funded sector and restructuring of the very fragmented national-level social health insurance funds. However, there was no comprehensive plan to unify and reform the sector. This study looks at the impact of the reforms on health finance, covering revenue collection, risk pooling and the purchasing and provision of health services. It found that the introduction of cost recovery by self-managed hospitals increased their budgets only marginally and competition among health insurance funds did not reduce fragmentation as expected. Although reforming the Solidarity Redistribution Fund and introducing a single basic package for the insured was an important step towards equity and transparency, the extent of risk pooling is still very limited.

Healthcare sustainability and the challenges of innovation to biopharmaceuticals in Canada

Z.R.S. Rosenberg-Yunger and others

Health Policy, vol. 87, 2008, p. 359-368

Introducing expensive biopharmaceuticals while simultaneously ensuring a sustainable healthcare system is complex and difficult. Ultimately, health system funders may be forced to refuse to pay for beneficial but expensive treatments. Their refusal to pay for beneficial innovative drugs may in turn adversely affect research and development of new treatments. Tensions thus exist between governments' desire to increase biotechnology innovation and their need to contain healthcare costs. Using Canada as a case study, this article: 1) reviews government initiatives in biotechnology in health innovation; 2) discusses how innovation in biopharmaceuticals challenges health system sustainability; and 3) explores how the tension between innovation and sustainability can be addressed using fairness and legitimacy.

The current healthcare policy agenda in the USA is focused partly on reforming payments and care delivery. Most of these reforms must rely for their success on collaboration between hospitals and medical staff to coordinate care and deliver it efficiently within budgetary limits. Hospitals and their medical staffs are engaged in a variety of collaborative arrangements labelled hospital-physician relationships. This article describes the continuum of hospital-physician relationships that providers have developed, the goals they are designed to achieve, and their performance to date. This continuum spans three types of integration - non-economic, economic and clinical - but the authors focus on economic integration and its impact on clinical integration.

The impact of the introduction of market incentives on occupational health services and occupational health professionals: experiences from the Netherlands

H.N. Plomp

Health Policy, vol. 88, 2008, p. 25-37

Between 1994 and 1998 a fundamental reform of the regulation of occupational health and safety was implemented in the Netherlands. Direct regulation by government, which had been in place since the nineteenth century, was replaced by 'self-regulation by stakeholders', stimulated by financial (market) incentives. Occupational health services accustomed to operating as monopolies in their regions were forced to compete for business with other suppliers. This paper explores the impact of the reforms on the market for occupational health services and occupational health professionals from 1994-2005.

Local access to care programs (LACPs): new developments in the access to care for the uninsured

L.A. Blewett, J. Ziegenfuss and M.E. Davern

Milbank Quarterly, vol. 86, 2008, p. 459-479

Some local communities in the USA are responding to gaps in employer-sponsored health insurance coverage and overburdened traditional safety net providers by developing local programmes to give uninsured adults coordinated access to local healthcare providers at low cost. This article examines a subset of these initiatives which it calls local access to care programmes. These are locally organised and financed programmes that provide a structured set of healthcare benefits and services to uninsured working-age adults.

In Italy, public resources provided through the national healthcare system cover the majority of total pharmaceutical expenditure. Since the early 1990s legislative, administrative and fiscal powers related to the healthcare system have been devolved to the 21 Regional Governments. Regions are experimenting with various strategies to govern drug use and expenditure, and are differentiating their approaches, leading to an ever-changing and complex institutional scenario. Pharmaceutical companies have created the new professional role of regional affairs manager with the task of monitoring different regional developments and of establishing relationships with the public actors in charge of pharmaceutical policies.

Public purchasers contracting external primary care providers in Central America for better responsiveness, efficiency of health care and public governance: issues and challenges

J. Macq and others

Health Policy, vol. 87, 2008, p. 377-388

National health systems in Latin America have been criticised for poor accessibility, poor quality of care and poor management. These problems have been addressed in many cases by contracting out primary care provision to for-profit private providers, community-based organisations, local government, and semi-autonomous agencies within the public sector. This paper explores the complex issues surrounding such contracting out of primary care provision using case studies from Costa Rica, Guatemala, Nicaragua and El Salvador.

Results confirm that:

contracting out requires not only technical but also political choices

it cannot be considered to be a mechanical process.

The unpredictability of its evolution requires a flexible and reactive approach.

The relationship between reproductive rights and prevalence of HIV among women in developing countries

L. Johnson

Journal of Comparative Social Welfare, vol. 24, 2008, p. 143-152

The rate of HIV infection among women in the developing world is rising. The goal of this study was to assess the effectiveness of a reproductive rights based approach to reducing HIV rates among women in developing countries. Reproductive rights refer to the extent of the control that women can exercise over decisions concerning marriage, regulation of fertility, engagement in sexual relations, and safe childbirth. The research found a positive relationship between reproductive rights and HIV rates in women, lending support to a reproductive rights based approach to reducing HIV infection.

Rethinking policies for the retention of allied health professionals in rural areas: a social relations approach

K. O'Toole and others

Health Policy, vol. 87, 2008, p. 326-332

Retaining allied health workers in rural areas is a recognised problem that haunts Australian policymakers at state and federal level. Studies usually focus on the practitioner as a public employee and how they fit into given organisational structures. This paper highlights the significance of the private sector in the retention of allied health professionals in rural areas through data derived from a survey conducted in South West Victoria. Results suggest that allied health professionals in private practice are more likely to stay put in rural areas. It is concluded that retention policies should look beyond personal and organisational issues associated with bureaucratic relations to aspects of market and associative relations that can act to embed people in local communities.